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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050-0039 <br /> �T Generator ID Number <br /> UNIFORM HAZARDOUS 2.Page of 3.Emepricy Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFESTe%044 ? 3231 SKS <br /> 5.Ge:nerator's Name and Mailing Address Generators Site Address(if different thIn P.R. <br /> AZ 1111, <br /> CP '35-,-7'4@,- 0 6 <br /> Generators Phone: oc OL <br /> 6.Transpoler 1 Compan�Name <br /> T 61 U.S.EPA ID Vj" <br /> T W— Z,92 ,4,0Q,-,,,— - --11211000P I <br /> 7 Transporter 2 Company Name <br /> 8 Designated Facility Name and Site Address <br /> ,J-HPIN '4PrR)30Pt' <br /> I , U.S.EPA ID Numb4f <br /> lopi SERRYF99P <br /> Facility's Phone. GAD059 ,49 <br /> 43 1(A <br /> 9a. 9b U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol.1. <br /> 13.Waste Codes <br /> .4-11AJ+:1 'i-.-• W""' V <br /> 0 WFIC) M.BIR I ri. F-'E 1,pfli. *1 <br /> LLJ <br /> Z 2. <br /> UJI <br /> 3. <br /> 4 <br /> 14 Special Handling Instructions and Additional Information <br /> R 1 Y E 1, T b P El A J N L 1 C L"N's JF <br /> 15. GENERATOR'S/OFFEROR'SCER11FICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> Generolor's/Offeror's Printed/Typed Name Signature <br /> Month Day Year <br /> + <br /> ri 16 International Shipments <br /> Import to U.S. El Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only). Date-leaving aving U.S.: <br /> WL17.Transporter Acknowledgment of Receipt of Materials <br /> Li <br /> Transport1 Printed/Typed Name <br /> Signature Month Day Year <br /> 0 <br /> j <br /> Z Transporter 2 Printedrryped Nal Signature <br /> < Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection E]Full ReMcbw <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL =acility's Phone. <br /> w18c.Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> 19 Hazardous Waste Report Management Method Codes(i.e codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1 2, <br /> C3 1 1 1 1 4, <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Orinted/Typed Name Signature Month Day Year <br /> EPA Form 87.00.-22(Rev 3-05) Previous editions are obsolete, GENERATOR'S INITIAL COPY <br />